VIEWPOINT
CLINICAL PRACTICE
Selection of Muscles for Botulinum Toxin Injections in Cervical
Dystonia
Wolfgang H. Jost, M.D.,1,* Laurent Tatu, M.D. 2
In the last 30 years, treatment of cervical dystonia (CD) has
come to focus on botulinum neurotoxin as the preferred
method of choice.1 On the one hand, a considerable number of
controlled studies have confirmed its high degree of efficacy in
open and double-blind studies, with a responder rate of
between 58% and 95%, and usually at 80%.2 On the other
hand, however, the most frequent adverse effects are difficulty
in swallowing and weakness of neck muscles.2 These points
highlight the current problems of recent work and their poten-
tial solutions. If we fully analyze movement patterns and inject
the muscles concerned with an adequately adjusted dose, then
the responder rate should be higher and the occurrence of dis-
orders in swallowing should be lower.3 One major advance for
selecting the relevant muscles came with our ability to distin-
guish at just which level of the cervical spine the muscles do
attach.3 A second major advance was the introduction of sonog-
raphy for better targeting the muscles and also for properly
locating muscles.4 Hereby, we are able to inject the muscles
precisely, even deep muscles.4
Anatomy, Muscle Functions, and CD
Before deciding on any particular muscles, an analysis and classi-
fication of their movement pattern has to be completed first,
and this requires knowing the muscles’ origins, their insertions,
and their functions. We proposed here a synthetic view of the
anatomic organization of the main cervical muscles (Table 1)
and schematic view of their action in CD according to the so-
called Col-Cap concept (Fig. 1).
Broadly speaking, the three dimensions of movement can be
distinguished. We always have to keep in mind the fact that the
cervical spine consists of several vertebrae, joints, and their par-
ticular, concomitant levels of movement. From a functional
point of view, two levels of movement can be defined: the
upper one between the skull and C2 and the lower one
between C2 and C7. The C2 vertebra can then be regarded as
a kind of fixed point. Although this was not considered impor-
1
Department of Neurology, University of Freiburg, Freiburg, Germany; 2Departments of Anatomy and Neurology, CHU Besancßon, University of
Franche-Comt
e, Besancßon, France
*
Correspondence to: Prof. Wolfgang Jost, University of Freiburg, Germany, Breisacher Straße 64, 79106 Freiburg, Germany; E-mail: wolfgang.
jost@uniklinik-freiburg.de
Keywords: anatomy, botulinum toxin, cervical dystonia, cervical muscles, therapy.
Relevant disclosures and conflicts of interest are listed at the end of this article.
Received 5 December 2014; revised 1 March 2015; accepted 3 March 2015.
Published online 7 May 2015 in Wiley InterScience (www.interscience.wiley.com). DOI:10.1002/mdc3.12172
224
TABLE 1 Anatomic patterns of the main cervical muscles
Posterior cervical muscles
Trapezius pars descendens
Linea nuchalis superior—Clavicula (lateral part)
Splenius capitis
Processus spinosus C3-Th3—Processus mastoideus
Splenius cervicis
Processus spinosus Th3-Th5—Processus transversus C1-C2
Semispinalis capitis
Processus transversus C3-Th6 and processus spinosus
C3-Th1—Linea nuchalis superior
Semispinalis cervicis
Processus transversus Th1-Th6—Processus spinosus C2-C7
Longissimus capitis
Processus transversus C3-Th3—Processus mastoideus
Longissimus cervicis
Processus transversus Th1-TH6—Processus transversus C2-C6
Obliquus capitis inferior
Processus spinosus C2—Processus transversus C1
Lateral cervical muscles
Sternocleidomastoideus
Suprasternal notch and clavicula (medial part)—Processus
mastoideus and linea nuchalis superior
Levator scapulae
Processus transversus C1-C4—Scapula (angulus superior)
Scalenus medius
Processus transversus C2-C7—First rib
Scalenus anterior
Processus transversus C3-C6—First rib
Anterior cervical muscles
Longus capitis
Processus transversus C3-C6—Occipital bone (basilar part)
Longus colli
Processus transversus C2-C5—Atlas (anterior tubercle)
tant in the classical definitions of laterocollis, retrocollis, antero-
collis, and rotatory torticollis, levels of movement of the neck
in relation to the trunk and for those of the head relative to the
neck have to be distinguished.
When muscles that induce a rotation rostral to C3 are dys-
tonic, the head demonstrates a pivotal movement in relation to
the neck, called a torticaput. If movement takes place caudal to
C2, a rotation of the neck occurs in relation to the trunk,
termed torticollis. The position of the larynx offers help here in
clinical orientation: In cases of torticaput, the larynx remains
© 2015 International Parkinson and Movement Disorder Society
doi:10.1002/mdc3.12172
 W. H. Jost and L. Tatu
Figure 1 Subtypes of cervical dystonia according to the Col-Cap concept, with the muscles involved (m, main; s, secondary muscle).
rather more in a medial position, and in torticollis it rotates
laterally (Fig. 1). Of course, in cases of torticollis, the head is
also rotated, but the main muscles involved act on the C2 to
C7 level.
With a lateral flexion, dystonia in the muscles that have
their site of origin or insertion in the skull or the first cervical
vertebra, induces a malposturing only of the head, but a
proper posture of the cervical spine (laterocaput). If those
muscles, which originate or insert between C2 and C7 are
involved, then the neck is flexed, thus corresponding to lat-
erocollis. In this case, the head and neck are in the same plane
(see Fig. 1). Of course, the two conditions can occur in com-
mon in cases.
A lateral shift, finally, means the combination of laterocollis
to the one side plus a laterocaput to the contralateral side
(Fig. 1).
A similar differentiation obtains for head and neck flexion:
anterocaput versus anterocollis and retrocaput versus retrocollis
(Fig. 1).
Some more-specific patterns can be described: An anterior
shift signifies the combination of anterocollis with retrocaput,
and a lateral shift means the combination of laterocollis to the
one side plus a laterocaput to the contralateral side.
doi:10.1002/mdc3.12172
VIEWPOINT
Another semiological issue frequently observed in CD is
shoulder elevation. In some cases, it should be seen not as
dystonic, but rather as a compensatory movement.
Discussion
Our recommendations here have considered our own many
years of clinical experience, anatomical and electromyographical
studies, the most recent data from work in sonography, and
publications in the field. Nonetheless, they, of course, remain
but a preliminary orientation and simplification. The majority
of patients present with combinations of different forms, which
means their respective musculature has to be selected as well.
Initial treatment stipulates considering just which muscles are
primarily involved and usually begins with the muscles most
strongly affected.
The more complex the CD becomes, the more difficult is
the final selection of muscles for treatment. This necessitates
a thorough neurological examination and, frequently, an
electromyographical examination.5 The advantage in using
sonography is that we can visualize the targeted muscle and
inject it with direct sight control.4 The disadvantage is that
we cannot decide whether the muscle is actually involved in
MOVEMENT DISORDERS CLINICAL PRACTICE 225
 VIEWPOINT
the dystonia at all, something which is better detailed using
electromyography (EMG), which, however, does not aid in
reliably assigning the activity to one specific muscle. Another
problem is that random EMG activity (which is meant to
serve actively balancing out the dystonic posturing and
movements) can be mistaken for dystonic activity. It would
be an ideal situation if physicians thus have not only access
to both techniques, but also extensive experience in their
use.
Taking these aspects into consideration means that the rele-
vancy of certain muscles has been lessened, for example, that of
the sternocleidomastoideus muscle, whereas others, considered
of less importance to date, have attained key status, such as the
levator scapulae and the obliquus capitis inferior muscles
(Fig. 1).
The problem of dystonic tremor is still unresolved as of yet.
In this case, the underlying CD is primarily treated, but then
the tremor usually does not improve or even worsens. Often,
the contralateral muscles were injected as well, such as the semi-
spinalis and splenius capitis muscles, with no clear evidence
until now.
Unfortunately, the scales and ratings presently in use are
not sufficiently valid to assess the forms of dystonia detailed
above. This means that some of the different forms are rated
inadequately.6 In any future revisions of these rating scales,
this would have to be taken into consideration. In addition,
the actual therapeutic success of earlier studies will now
have to be viewed far more critically in light of these
arguments.
226 MOVEMENT DISORDERS CLINICAL PRACTICE
Kinetic of Muscles and Head Pattern
Author Roles
Manuscript Preparation: A. Writing of the First Draft,
B. Review and Critique.
W.H.J.: A, B
L.T.: A, B
Disclosures
Funding Sources and Conflicts of Interest: The authors
report no sources of funding and no conflicts of interest.
Financial Disclosures for previous 12 months: W.H.J. and
L.T. are speakers and consultants for Allergan, Ipsen, and Merz.
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doi:10.1002/mdc3.12172